Provider Demographics
NPI:1639432578
Name:ZVENIGORODSKAYA, YELENA (MSED)
Entity Type:Individual
Prefix:MRS
First Name:YELENA
Middle Name:
Last Name:ZVENIGORODSKAYA
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3309 SURF AVE
Mailing Address - Street 2:APT 3C
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11224-1456
Mailing Address - Country:US
Mailing Address - Phone:718-872-8614
Mailing Address - Fax:
Practice Address - Street 1:3309 SURF AVE APT 3C
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11224
Practice Address - Country:US
Practice Address - Phone:347-673-8516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-15
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY610047121174400000X
NY619098121174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist